Insights February 2013

Danger of Simplification

Hugh Macleod and Dr. Doug Cochrane


Hi, once again back on the balcony of personal reflection. This time I am joined by Dr. Doug Cochrane, a leader of quality and patient safety improvement. We begin a conversation about the difference between complicated systems and navigating the complexity of the healthcare system. Complexity asks, how do things assemble themselves? Complexity looks at interacting elements and asks how do they form patterns and how do the patterns unfold given patterns may never be finished because they are open-ended. In healthcare this kind of inquiry can create reaction: traditional science does not like perpetual novelty. Newtownian laws are supposed to be unchanging. The question is whether we, as leaders, contribute to the complexity. That, at least, is the view of our critic, the Ghost of Healthcare Despair.

“Healthcare is complex, but you organize it in ways that make it complicated and highly specified. To be successful in the complex healthcare world, you need a different mindset. You need to walk the frontline to manage the complex. People will give freely if the environment is right — if it is respectful and open to possibilities. You do not make real, transformative changes because it is in your short term interest to drive your staff into the ground on the basis of false productivity, to satisfy both large and small politics of the moment.”

Far too often we apply simple solutions to complicated challenges, when in fact, the challenge was complex to begin with. And then we are surprised that we have only scratched the surface and pulled the wrong levers. Often we do not understand simple, complicated and complex problems. In simple problems like using a cookbook, the recipe is essential. It is often tested to assure easy replication without the need for any particular expertise. Recipes produce standardized products and the best recipes give good results every time.

Other problems, like sending a rocket to the moon, are obviously much more complicated. Formulae, or recipes, are critical but not sufficient. High levels of expertise in a variety of fields are necessary for success. In many critical ways, one rocket is similar to the next. Success with one rocket offers at least some assurance that the next mission will also be a success.

Raising a child, on the other hand, provides experience, but no guarantee of success with the next child. Although experience can contribute to the progress in valuable ways, it provides neither necessary nor sufficient conditions to assure success. Every child is unique and must be understood as an individual. The result is uncertainty of outcome. The complexity of the process and lack of certainty, however, do not lead us to the conclusion that it is impossible to raise a child.

Simple systems contain few interactions and are extremely predictable. The same action produces the same result every time. There is also a high degree of agreement on outcomes and processes. The process for obtaining a blood sample via venipuncture would be an example of a simple system.

Complicated systems have many moving parts or tasks in a process, with many possible interactions.  But they operate in a patterned way. It is possible to make accurate predictions of how a complicated system will behave. The patient admission process is an example of a complicated system.

Complex systems are characterized by features that may operate in patterned ways, but the interactions within them are continually changing. With complex systems, there is a low level of agreement on the outcomes or processes because situations involve multiple individuals or processes and there is a high degree of heterogeneity among them. For example, different departments are involved. In addition, teams may self-organize around areas of competence, making relationships and resulting interactions even more fluid. An example of a complex system is the process for transferring a patient between organizations — say, a trauma patient requiring air ambulance from a community hospital to a tertiary centre — as it requires multiple handovers and inter-agency collaboration.

The degree of interconnectedness and the relationships between the different parts of the system also help to differentiate complicated and complex scenarios. Labeling a challenge as complicated or complex is one aspect to consider when deciding how it should be analyzed. The determination should be made by consulting with those responsible for analysis. Additionally, challenges that appear to be simple early in analysis may be deemed complicated once more is known and the challenge is better understood. It is important to refrain from making assumptions early in the process as to the degree of complexity without having a full understanding of the incident circumstances. System characteristics that help differentiate these systems include:

  1. The degree and accuracy with which the steps in the system can be specified, and conversely, the degree to which the system adapts case by case.
  2. The predictability of the process in detail and of the outcomes based on a properly executed process, the process of linearity.
  3. Whether there are subsystems, interactions and interdependencies.
  4. The requirement for emergent behaviour and creativity to solve the problem.

Most attempts to intervene in healthcare treat the challenge or problem as if they were merely complicated. We demonstrate this failure of understanding though applications of the fad of the day, regulatory or legislative change to get the challenge off the front page of the newspaper. And the outcome often results in the law of unintended consequences. We pull the wrong levers. It is time to convert most critical complicated questions into complex ones. For example:

  1. The complicated question–“What are the structures we need to make the healthcare system sustainable”? becomes the complex question – “How do we build on current structures and relationships to stabilize and enhance healthcare delivery”? and,
  2. The question–“Can we afford increasing care and treatment for an aging population”? would become – “How can we provide care and treatment that makes everyone feel the system will be there, should their family need it”? and
  3. The question– “What do we have to give up to support the most effective and advanced technology (or drugs)”? would become –“How can we help healthcare institutions and professionals enhance the quality of services and innovation in technology and drugs?” and finally,
  4. The question–“How much should Canada pay for their healthcare”? would become – “How can we contribute even more to the Canadian identity?”

Healthcare transformation cannot be reproduced from its description by using a recipe book approach any more than listing the hues and tones in Boticelli’s Birth of Venus can reproduce the masterpiece. There is no single book that can provide the road map, we must understand the complexity of the healthcare system and with it local plurality, history, culture, commitment, leadership and readiness for transformation.

But for the adaptability and learning that complex system problems force upon us, the Ghost of Healthcare Despair would maintain a firm grip on progress. Over time, systems change. That which was complex, unpredictable and unspecified, can be specified. Personal based medicine is the most exciting example of this. Rendereing the complex complicated (or simple) will rapidly follow the definition of tumor specific genetic and epigenetic markers. The problem, in the individual patient will be simplified, the treatment will be definable and the outcome predictable. The adoption of effective clinical information systems and harmonization of medical records under the direction of patients and available for all authorized users will remove the rework and cross checking that is characteristic of complicated system in healthcare. And simple solutions will be readily adopted. Guidelines based on proven evidence will be adopted as a matter of fact. Patients will receive consistent care. Complex systems will always remain on the forefront of health care. But they are not carved in stone. Research provides the direction, innovation provides the process and providers care.

The strength of the Ghost of Healthcare Despair grows because we do not understand the differences between; simple, complicated and complex. This creates disconnects that leads to passive-aggressive behaviour that consumes negative energy, creates a sense of hopelessness, squanders public funds through inefficiencies and above all defeats a vision of creating a patient centered system.

Next Week’s Guest on the Balcony of Personal Reflection: C. Kushner in a conversation titled “The Patient Voice A Value Game Changer”. 

Click here to see the First Series of Ghost Busting essays.

Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Hugh Macleod is CEO of the Canadian Patient Safety Institute. Dr. Doug Cochrane is Chair of the British Columbia Patient Safety and Quality Council and the Patient Safety and Quality Officer for British Columbia. He is a Professor at the University of British Columbia in Surgery (Neurosurgery)


Zimmerman B, Globerman S. Complicated and Complex Systems – What Would Successful Reform of Medicare Look Like. 2004.Commission on the Future of Healthcare in Canada

Savafly, Crawford-Mason (Summer 2001). Nun and the Bureaucrat Speech. 


Rob Robson wrote:

Posted 2013/02/26 at 10:43 AM EST

Thank you for a clear and cogent discussion of the simple, complicated and complex paradigm. You are absolutely right that we often ask the right questions and apply the tools, techniques or solutions that are applicable for a different kind of system (usually a simple one!).

Brenda Zimmerman's earlier work Edgeware provides many additional insights in this area.


Tonya Mahar wrote:

Posted 2013/02/26 at 03:08 PM EST

Thank you for referring to our work on complexity for the Romanow Commission. This is an excellent summary of our piece and a good application of our findings.

Sholom Glouberman


Susan Morrow wrote:

Posted 2013/02/26 at 05:02 PM EST

Thanks for this essay, and for highlighting a leadership dilemma in healthcare. However, I do take issue with the suggestion that complexity should be "solved" by moving the problem into the complicated/simple, predictive domains. Complexity per se is not a bad thing - for example, innovation primarily exists in the complex domain. But traditional leadership tools help us mostly in the complicated/simple domains. Leading complexity consists of defining boundaries, seeding the space, paying attention to the patterns that emerge, providing stimulus to the desired patterns and dampening the undesired patterns. Perhaps what is needed are a few more tools in the leadership toolbox.


Darrell Horn wrote:

Posted 2013/02/26 at 08:31 PM EST

I agree with Ms. Morrow. The vexing issues presented by complexity are not broadly amenable to reducible solutions. Resilience is the key. Paul Cilliers wrote in 1998 "Order is not imposed; it emerges from the
multitude of relationships and interactions between component parts. Success in a
complex system flows not from having it follow one best method but from a diversity
of responses that allow it to cope with a changing environment."


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